NATIONAL GUIDELINES FOR THE HEALTH CRISIS MANAGEMENT

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CENTER FOR HEALTH CRISIS

MINISTRY OF HEALTH OF THE REPUBLIC OF INDONESIA

2023

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DECREE OF THE MINISTER OF HEALTH OF THE REPUBLIC OF INDONESIA NUMBER HK.01.07/MENKES//2023

CONCERNING

NATIONAL GUIDELINES FOR THE HEALTH CRISIS MANAGEMENT BY THE GRACE OF GOD ALMIGHTY

THE MINISTER OF HEALTH OF THE REPUBLIC OF INDONESIA,

Considering : a. Whereas, in the context of supporting health resilience and increasing the quality of health services and protection to the community, it is necessary to possess an integrated and coordinated health crises management;

b. Whereas, several technical instructions are available for carrying out efforts to overcome the health crisis, namely:

1. Technical instructions for the Health Cluster and Health Emergency Operation Center

2. Technical instructions for Health Reserve Personnel 3. Technical instructions for the Emergency Medical Team 4. Technical instructions for Health Logistics of the Health

Crisis Management

5. Technical instructions for Minimum Service Standards of Health Clusters during a Health Crisis Emergency 6. Technical instructions for Assessment on Post-Disaster

Needs (Jitu Pasna) of the Health Sector

7. Technical instructions for Health Crisis Management Information Systems

8. Procedures for Preparing Medical Emergency Services to Anticipate Mass Casualty Incidents at Football Achievement Sports Activities

9. Guidelines on Community Empowerment for the Health Crisis Management

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c. Whereas, in order to facilitate the implementation of the Health Crisis Management, it is necessary to integrate all technical instructions into the National Guidelines for Health Crisis Management;

d. Whereas, based on the considerations referred to in letters a, b, and c, it is necessary to stipulate a Decree of the Minister of Health concerning National Guidelines for Health Crisis Management.

Recalling : 1. Law Number 4 of 1984 concerning Outbreaks of Infectious Diseases (State Gazette of the Republic of Indonesia of 1984 Number 20, Additional State Gazette of the Republic of Indonesia Number 3273);

2. Law Number 24 of 2007 concerning Disaster Management (State Gazette of the Republic of Indonesia of 2007 Number 66, Additional State Gazette of the Republic of Indonesia Number 4723);

3. Law Number 36 of 2009 concerning Health (State Gazette of the Republic of Indonesia of 2009 Number 144, Additional State Gazette of the Republic of Indonesia Number 5063);

4. Law Number 7 of 2012 concerning Social Conflict (State Gazette of the Republic of Indonesia of 2012 Number 116);

5. Law Number 6 of 2018 concerning Health Quarantine (State Gazette of the Republic of Indonesia of 2018 Number 128, Additional State Gazette of the Republic of Indonesia Number 128);

6. Government Regulation Number 21 of 2008 concerning Disaster Management (State Gazette of the Republic of Indonesia of 2008 Number 42, Additional State Gazette of the Republic of Indonesia Number 4828;

7. Government Regulation Number 22 of 2008 concerning Funding and Management of Disaster Aid (State Gazette of the Republic of Indonesia of 2008 Number 43, Additional

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State Gazette of the Republic of Indonesia Number 4829);

8. Government Regulation Number 2 of 2015 concerning Regulations for Implementing Law Number 7 of 2012 concerning Handling of Social Conflicts (State Gazette of the Republic of Indonesia of 2015 Number 25);

9. Government Regulation Number 2 of 2018 concerning Minimum Service Standards (State Gazette of the Republic of Indonesia of 2018 Number 2, Additional State Gazette of the Republic of Indonesia Number 6179);

10. Regulation of the Minister of Health Number 75 of 2019 concerning Health Crisis Management (State Gazette of the Republic of Indonesia of 2019 Number 1781);

11. Regulation of the Minister of Health Number 4 of 2019 concerning Technical Standards for Fulfilling the Basic Services Quality of Minimum Service Standards in the Health Sector (State Gazette of the Republic of Indonesia of 2019 Number 68) and its amendments.

DECIDED :

Determines : DECREE OF THE MINISTER OF HEALTH CONCERNING NATIONAL GUIDELINES FOR THE HEALTH CRISIS MANAGEMENT

First : The National Guidelines for the Health Crisis Management referred to in the First Dictum are included in the Attachment to this Decree.

Second : Guidelines as referred to in the Second Dictum shall be used as a standard for the Health Crises Management.

Third : This Decree comes into effect from the date it is stipulated with the provision that if in the future mistakes are found in the Decree, corrections/improvements will be made as appropriate.

Stipulated in Jakarta

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on the date of

THE MINISTER OF HEALTH

OF THE REPUBLIC OF INDONESIA

BUDI G. SADIKIN

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ATTACHMENT

DECREE OF THE MINISTER OF HEALTH OF THE REPUBLIC OF INDONESIA

NUMBER CONCERNING

NATIONAL GUIDELINES

FOR THE HEALTH CRISIS MANAGEMENT

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SECTION I INTRODUCTION

1.1 BACKGROUND

Indonesia is a disaster-prone area. Based on the Indonesian Disaster Risk Index (IRBI), not one region in Indonesia is at low risk of disasters each year.

Indonesia has 127 active volcanoes and is traversed by three tectonic plates: the Indo-Australian, Eurasian, and Pacific plates. This makes Indonesia vulnerable to threats of volcanic eruptions and earthquakes. High rainfall and environmental factors make the country susceptible to hydro-meteorological disasters. Additionally, Indonesia has many points of entry (including air, sea, and land routes), which increases the risk of disease/

biological threats from foreign countries that could have an impact on public health emergencies and potentially become non-natural disasters.

Several major disasters at the national, provincial, and district/ city levels have provided lessons on mobilizing health resources.

In responding to natural disaster emergencies, the number of mobilized resources is not a problem because when one area is affected by a disaster, help will come from other areas. However, the challenges lie in rapid and accurate responses, as well as effective management in the field. Some contributing factors include the lack of a database management system, incomplete resource needs calculation standards, and inadequate competencies of mobilized personnel.

Meanwhile, the experience of dealing with non-natural disasters (e.g., the COVID- 19 pandemic) has led to difficulties in mobilizing health reserve workforce due to the impact on all geographic areas. The quantity is insufficient, and the recruitment process during emergencies requires a lengthy process.

Based on the evaluation of disaster management experiences in Indonesia, including the COVID-19 pandemic, the Ministry of Health Affairs has initiated a transformation of the health system, with one goal being to create a strong and resilient health system capable of providing health responses for both national and global disasters. This is carried out through three main priorities: 1) strengthening domestic production of health equipment, raw materials for medicine, and vaccines; 2) strengthening adequate surveillance; and 3) strengthening the disaster and health emergency management system.

The strategic target for strengthening the disaster and health emergency management system is the establishment of Health Clusters at the national/ provincial/

district/ city levels and the establishment of registered and trained health reserve workforce.

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To achieve these targets, guidelines have been developed that provide technical instructions as outlined in the Ministry of Health Affairs Regulation No. 75/2019 Concerning Health Crisis Management, which resulted in the creation of the "National Guidelines for Health Crisis Management".

1.2 PURPOSE

This guideline serves as a reference for program managers and communities to implement health crisis management efforts during pre-, emergency, and post-health crisis phases.

1.3 SCOPE

This guideline covers the following:

1. Establishment of health clusters and operationalization of the Health Emergency Operations Center (HEOC).

2. Implementation of the Health Reserve Workforce program, including Emergency Medical Teams (EMTs).

3. Logistics management for health crisis response.

4. Minimum standards of health services by sub-sub-clusters.

5. Assessment of post-disaster needs (Jitupasna) in the health sector.

6. Management of the Health Crisis Management Information System (SIPKK).

7. Health crisis risk management at mass gatherings.

8. Community empowerment efforts to address health crises, including emergency response.

1.4 INTENDED AUDIENCE

1. Ministries and institutions.

2. Provincial and district/ city sub-national governments.

3. Health services facilities.

4. Professional organizations.

5. Educational institutions.

6. Businesses.

7. Media.

8. Community organizations.

9. Society.

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SECTION II

HEALTH CLUSTERS AND THE HEALTH EMERGENCY OPERATION CENTER (HEOC)

2.1 THE CONCEPT OF HEALTH CRISIS MANAGEMENT

A health crisis refers to an event or series of events that result in fatalities, injuries/ illnesses, displacement, and/or potential threats affecting public health, requiring a rapid response beyond the scope of normal routines and inadequate health capacity.

The determination of a health crisis emergency status falls under the responsibility of the Minister of Health Affairs or the Head of the Health Office based on the outcomes of a Rapid Health Assessment (RHA) that indicates a threat to public health.

If the President, a governor, district head, or mayor has declared a disaster emergency status, the health crisis emergency status will automatically apply without the need for a stipulation from the Minister of Health Affairs/ Head of Health Office.

Health crisis management involves three phases: before the health crisis (pre- health crisis), during the health crisis emergency, and after the health crisis (post-health crisis). Management efforts focus on health crisis risk reduction activities before a health crisis occurs, as shown in the following illustration.

Figure 2.1 Health Crisis Management Paradigm

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4 2.1.1 Pre-Health Crisis

Health crisis risk reduction comprises a series of activities aimed at increasing the capacity of health resources, managing the threat of a health crisis, and reducing vulnerability.

Health Crisis Risk = Hazard X (Vulnerability / Capacity)

Figure 2.2 Principles of Disaster Risk Management Where:

a. Hazard = an event or events that can cause Health Crisis hazards based on parameters such as intensity and probability of occurrence.

b. Vulnerability = the state or nature/ behavior of humans or society that causes an inability to face a hazard or threat of a Health Crisis. It consists of physical, economic, socio-cultural, and environmental vulnerabilities. The following provides an explanation:

- Socio-cultural vulnerability describes the level of social and cultural vulnerability in facing threats/ hazards. Socio-cultural indicators related to health problems include the number of vulnerable groups, the index of public health status, hygiene/ behaviors/ customs/ local wisdom in the community, immunization coverage, etc.

- Economic vulnerability describes the level of economic fragility in facing threats/ hazards. It affects access to health services. Economic indicators related to health problems include ownership of health financing guarantees/

health insurance.

- Physical/ infrastructure vulnerability describes a physical/ infrastructure condition that is vulnerable to certain hazard factors. Examples include the vulnerability of buildings, infrastructure, or the location of health service facilities in disaster-prone areas.

- Environmental vulnerability refers to an environmental condition that is prone to certain hazard factors. For example, the status of environmental health in a given area.

c. Capacity = the strength and potential possessed by individuals, families, communities, and governments that enable them to prevent, mitigate, prepare for, respond quickly to, or recover from a Health Crisis.

Capacity building efforts are carried out by:

a. Strengthening the managerial and technical capabilities of human resources.

b. Conducting health crisis risk assessments.

c. Formulating, publicizing, and implementing policies or standards for health crisis management.

d. Developing an information system for health crisis management.

e. Developing a health crisis management plan, consisting of:

- A general health crisis management plan for all hazards.

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- Contingency or Renkon plan, which is a forward planning process (whether it will occur or not) for emergency response preparedness. It identifies potential disaster situations, scenarios, resource needs (gap analysis), sets goals, determines technical and managerial actions, and agrees on a joint response system and potential guidance to prevent or better respond in emergency situations. Renkon is prepared to face emergency situations caused by a single hazard and possible collateral disasters (if any). Renkon must be consistent with the general health crisis management plan (Renkon template in Appendix 1).

f. Developing the capacity of health service facilities to withstand disasters.

g. Conducting simulations and field rehearsals in the health sector.

h. Empowering communities to respond to health crises.

i. Developing an early warning system.

j. Forming Emergency Medical Teams (EMTs), Rapid Health Assessment (RHA) teams, Public Health Rapid Response Teams (PHRRTs), and other health teams.

k. Preparing health infrastructure facilities and adequate health supplies for emergency response efforts.

2.1.2 Health Crisis Emergencies

The response during the emergency phase of a health crisis aims to rapidly and appropriately address all emergency conditions in order to save lives, prevent further disability, and ensure that health programs operate with the fulfillment of minimum health service standards.

During the emergency phase of a health crisis, health crisis management is carried out through the following activities:

a. Conducting a Rapid Health Assessment (RHA).

b. Activating the Health Emergency Operations Center (HEOC).

c. Developing and implementing a health crisis operation plan based on the results of the RHA and health sector contingency plans (for those that are already in place).

Health Crisis Response Plans in the Pre-Crisis and Emergency Phases

PRE-HEALTH CRISIS HEALTH CRISIS EMERGENCY

Risk Analysis:

Mapping hazard (H), Vulnerability (V), Capacity (C), Risk = (H X V)/C

Rapid Health Assessment (RHA):

determine crisis conditions, assess health problems & potential risks, and identify needs

Early Warning System ● Reference to preparation of

operational plans

● Early prediction pending RHA results

Contingency plan (specific, single hazard, calculates resource requirements based on scenarios)

Operations Plan (location, impact, resource mobilization, operation agreement)

Continue to be updated based on development information

Figure 2.2 Correlation between health crisis management plans at the pre-health crisis and health crisis emergency phases

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d. Developing a response map, which presents sub-national capacities in responding to emergencies, including hazard, capacity, vulnerability, response flow, and evacuation route mapping.

e. Mobilizing sufficient human resources, health infrastructure, and health supplies in a regulated manner to avoid infrastructure bottlenecks at any given time.

f. Ensuring that health services for affected communities are delivered according to standards while considering the interests of vulnerable groups.

g. Intensifying monitoring of the situation's developments.

h. Implementing health crisis communication strategies.

2.1.3 Post-Health Crisis

Responses during the post-health crisis phase aim to restore the health system's pre-crisis conditions and build back better, safer, and more sustainable. The following activities are involved:

a. Conducting a post-health disaster resource needs assessment (Jitupasna) in the health sector.

b. Formulating a health rehabilitation and reconstruction plan.

c. Implementing the health rehabilitation and reconstruction plan.

d. Monitoring and evaluating the implementation of health rehabilitation and reconstruction efforts.

2.1.4 Organization

Health crisis management is carried out through a cluster system at the national, provincial, and district/ city levels, where capacities are grouped based on their service functions. The objective is to improve coordination, collaboration, and integration in managing health crises. The health cluster is an essential component of the disaster management cluster and must actively coordinate with the Disaster Emergency Management Command Post (Posko PDB).

Figure 2.3 Disaster Cluster System (BNPB Head Decree No. 173/2014)

The Health Cluster is a group of actors dealing with health crises who have the competence in the health sector to coordinate, collaborate, and integrate to meet the needs of health services, originating from the national government or sub-national governments, private sector/ business institutions, academia, media, and community groups.

The Health Cluster was formed during the pre-health crisis period and is coordinative in nature to reduce the risk of health crises. Its members are institutions/

organizations related to health crisis management in the region. During a health crisis emergency, the Health Cluster is commando in nature, and its members consist of all

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health crisis emergency response actors within the area (existing staff) and health reserve workforcefrom outside the area who come to help at the affected location.

The Health Cluster comprises several sub-clusters, including:

1. Health services sub-cluster, which is responsible for organizing individual health services, especially emergency assistance services, pre-health service facilities, and referrals.

2. Disease control and environmental health sub-cluster, which is responsible for carrying out disease control and environmental health efforts.

3. Reproductive health sub-cluster, which is responsible for organizing reproductive health service activities.

4. Mental health sub-cluster, which is responsible for organizing efforts to optimally address mental health and psychosocial problems.

5. Nutrition service sub-cluster, which is in charge of administering nutrition services.

6. Sub-cluster for identification of victims who died as a result of disasters (disaster victim identification/ DVI), which is responsible for carrying out the identification of dead victims and their management.

7. Health promotion sub-cluster, which is responsible for organizing health promotion efforts.

The health cluster comprises:

a. National Health Cluster, formed by the Minister and coordinated by the Head of the Center responsible for the health crisis sector.

b. Provincial Health Cluster, formed and coordinated by the Head of the Provincial Health Office.

c. District/ City Health Cluster, formed and coordinated by the Head of the District/

City Health Office.

2.2 ACTIVATION OF THE HEOC/ HEALTH CLUSTERS

During a health crisis emergency, the Health Cluster Coordinator activates the Health Emergency Operation Center (HEOC), which is a health management system that integrates various facilities, devices, procedures, trained resources, and information and communication technology systems as a control center for coordination and collaboration to monitor, detect, prevent and respond to health crises in an organized and measurable manner. The Health Cluster Coordinator also serves as the HEOC Chair.

The HEOC is responsible for providing health services and protection to affected communities through health crisis emergency response activities, as well as carrying out command, coordination, and collaboration functions with all policy stakeholders engaged in the health sector when a health crisis occurs. At the provincial level, the provincial HEOC is the main post, and HEOCs can be formed in districts/ cities as field posts. At the national level, the national HEOC is the main post, and HEOCs can be formed in provinces/ districts/ cities as field posts. The field post is the command area of the main post.

The HEOC is part of the organizational structure of the Disaster Emergency Management Command Post (Posko PDB), as shown in Figure 2.4.

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Figure 2.4 The position of the Health Crisis Center is based on BNPB Decree No.

3/2016 Concerning the Emergency Disaster Management Command System

Figure 2.5 Health Emergency Operation Center (HEOC) Organizational Structure The Head of the HEOC holds regular coordination meetings attended by all field coordinators and representatives of elements controlled by the Head of the HEOC, and the results of these meetings must be reported to the PDB Command Post. The duties of each field coordinator are as follows:

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9 a. Planning Coordinator

1) Prepare an operational plan for managing a health crisis emergency response based on the results of the RHA and Renkon (if any).

2) Update the operational plan and response maps in accordance with the situation and conditions for managing an emergency health crisis.

3) Provide recommendations for managing health crises.

4) Evaluate the management of emergency health crises.

5) Evaluate the capacity and load of health service facilities.

6) Conduct internal coordination meetings.

b. Operations Coordinator

1) Carry out the operational plan that has been prepared.

2) Coordinate health service efforts (pre-hospital as well as internal and between hospitals) during a health crisis emergency.

3) Coordinate and mobilize health reserve workforce, including the Medical Emergency Teams (EMTs), and Community Health Teams (PHRRTs).

4) Assign and monitor the implementation of health services by health reserve workforce.

5) Ensure that the referral system during a health crisis can function well from prehospital and between hospitals.

c. Logistics Coordinator

1) Facilitate additional health logistics required by the Health Cluster.

2) Plan the needs, procurement, provision, storage, distribution, recording, and reporting of health logistics during a health crisis emergency.

3) Manage donation logistics.

d. Data, Information, and Surveillance Coordinator

1) Continuously monitor the conditions of health crises and provide up-to-date information on the situation and management of health crises to the head of the HEOC.

2) Record health reserve workforce who assist in responding to health crisis emergency management and create a database.

3) Manage data and information, which includes collecting, processing, analyzing, preparing reports, and disseminating data and information on managing emergency health crises.

4) Conduct risk communication and community empowerment activities, which include public communication efforts and addressing rumors/ fake news.

5) Carry out health surveillance activities at the disaster site.

7) Manage data and information dissemination related to health crisis management.

e. Finance and Funding Coordinator

1) Manage the funding needs of all HEOC operations.

2) Manage financial donation assistance.

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3) Maintain financial records and report to the head of the HEOC.

2.3 RISK MAPS AND RESPONSE MAPS

2.3.1 Risk Maps

A risk map is a data visualization tool used to communicate specific risks and help sub-national regions identify and prioritize risks associated with the area. The purpose of a risk map is to increase sub-national understanding of its risk profile, clarify the nature and impact of risks, and improve sub-national risk assessment.

Risk maps are considered an important component of sub-national risk management as they help identify risks that require more attention. Identified risks that are included in the high severity level can then be prioritized by the sub- national region.

Risk maps should be prepared before a health crisis occurs or during the pre- health crisis phase and should be included in the preparation of sub-national and health office contingency plans. The process of creating a risk map starts with identifying the hazards that have occurred or are likely to occur, the vulnerabilities and existing capacities, with the hope that increasing capacity can reduce the impact of potential risks.

Risk maps can be made either in digital or manual form and offer several benefits:

1. Offering a visualization.

2. Providing a comprehensive view of the impact of risks.

3. Helping sub-national regions improve risk management and governance by prioritizing risk management efforts

4. Allowing for the prioritization of risks to ensure that time and funds can be focused on potential damage.

The following is the process for creating a risk map:

1. Identify persistent or routine risks from hazards/ threats and understand the type of internal or external event.

2. Evaluate the risks from the hazard that occurs and estimate the frequency, potential impact, possible control processes that can be carried out, and determine the vulnerability of the area.

3. Prioritize the risks that occur, focusing on those with the most impact and implementing control processes to help reduce potential risks.

4. Regularly review and effectively manage the risk map as threats/ hazards develop and vulnerabilities change.

Before a disaster occurs, a risk analysis should be carried out by identifying what hazards will occur and assessing their impact, so the highest priority risk can be identified, e.g. earthquakes. Starting with determining the areas with the highest impact due to the earthquake and marking them in orange, those with moderate impact in yellow, and those with mild impact or far from the impact that might occur in green. Areas that are vulnerable as a result of the earthquake should then be identified. After that, all health facilities in the area should be marked on the map, both primary and referral, to determine capacity.

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The process for creating a risk map includes the following steps:

1. Prepare scenarios, or scenarios that have been prepared in a contingency plan.

2. Determine the disaster to be mapped.

3. Prepare a district map or sub-district map.

4. Determine the location of the possibility of a disaster that will occur by marking it in red (as a hazard map).

5. Determine areas that may be prone/ vulnerable to disasters from imminent hazards (as a vulnerability map), plotting the distribution of impacts, affected residential areas, and infrastructure.

6. Mark all health facilities in the area as a capacity map, both primary and referral.

7. Determine the response plan that can be carried out by the sub-national region (health cluster) based on the scenario and the possibility of a disaster that will occur.

8. Monitor at least once a year together with the contingency plan drawn up.

The following are some examples of risk map images that can be seen in the image below.

Figure 2.6 Risk Map based on earthquake hazards

The image above is a risk map based on earthquake hazards, including existing health facilities.

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Figure 2.7 Display of the overall Palu City risk map along with legends.

Figure 2.8 Enlarged risk map depicting hazards, vulnerabilities, and capacities in greater detail

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Creating a risk map requires the use of existing resources and collaboration across sectors, including BNPB/

BPBD, other Ministries/ Agencies, and academics. Disaster risk maps are accessible at http://inarisk.bnpb.go.id/.

Figure 2.9 Disaster risk map accessible at BNPB inarisk 2.3.2 Response Maps

Health crisis emergencies are characterized by health problems that exceed daily capacity and are followed by limited resources. In an emergency situation, we must respond quickly to save lives and prevent disability. A quick response is possible if a risk map has been prepared in advance, which enables us to quickly assess our existing capacity at the time of the emergency. To speed up our actions, a response map is required, which maps the location and extent of the disaster, the available capacity, and the assistance to be prepared.

Response maps are created in response to sub-national capacities to respond to emergencies, and are presented in the form of maps containing hazards, capacities, or visualizations of various information related to handling health crises.

Their goal is to mobilize health services more efficiently and effectively.

One of the objectives of creating response maps is to place volunteers efficiently, avoiding overlapping, and ensuring that volunteer teams are distributed properly, not piled up in one location. Response maps are important to ensure that volunteer teams can see their work areas. A response map is created when:

1. A disaster occurs.

2. The hazard or threat is a single hazard (e.g., an earthquake).

3. Areas of vulnerability, including vulnerable groups, are identified.

4. The available capacities in the area and health care facilities are identified.

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Figure 2.10 Response (vulnerability) map for a single hazard (earthquake) The vulnerability map contains information about evacuation places, vulnerable groups in the area, and areas that need evacuation.

Figure 2.11 Response (capacity) map

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The figure above shows a capacity map that displays the remaining capacity of a region after an earthquake, enabling us to understand which areas still require health services. The capacity is mapped as follows:

1. Health facilities that can still provide health services.

2. Human Resources (HR) in Puskesmas that can still provide services.

3. Human Resources (HR) in hospitals.

4. Health cadres or volunteers in the area.

Figure 2.12 Capacity response map of the Mobile Clinic Team

The figure above shows the capacity response map of the Mobile Clinic Team.

This map displays the medical team that will assist in Tapalang District, with each medical team recorded and placed in areas that require health services.

Figure 2.13 Manual response map

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The figure above shows a manual response map:

1. Green and yellow indicate volunteers assisting with primary care.

2. Red indicate volunteers assisting in hospitals.

3. Orange indicate volunteers at ship hospitals.

The development process of response maps includes the following steps:

1. Prepare a management kit and a map of the affected area.

2. Plot health facilities that can still provide services.

3. Mark health facilities that cannot provide services, including refugee camps requiring health services.

4. Place and organize volunteers who come to the health cluster in areas or health facilities that require assistance, as well as in evacuation sites that require health services.

5. Use different colors to identify primary and referral facilities to make it easier for everyone to see.

6. Monitor daily mobility on the map.

In conclusion:

a. Response maps are created when a disaster occurs.

b. Response maps should be placed where they are easily visible.

c. Response maps should be updated based on daily progress reports.

d. In sudden-onset disasters, a manual response map can be made using prepared management kits. If the situation permits, a new digital map can be made.

e. The data from the response map must be processed into information for determining the next operation and advocacy.

2.3.3 Differences Between Risk Maps and Response Maps

Table 2.1. Differences between Risk Maps and Response Maps

RISK MAP RESPONSE MAP

When is it prepared? Before disaster strikes After disaster strikes Hazard/ Threat Identifies past or

potential hazards/

threats

Single hazard

Considers all hazards Vulnerability Prepared based on

multiple identified threats

Prepared only when the threat has manifested Capacity All existing capacities in

the area, e.g. how many health facilities are there in the area

Considers the remaining capacity, e.g.:

- Health facilities that are still operational

- Health workers that still exists and can provide services

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RISK MAP RESPONSE MAP

- Health cadres/ volunteers Map creation tool

(management kit)

N/A as it is prepared before a disaster occurs

Must be prepared as it will be used during the disaster and will be needed throughout the emergency response period

Equipment Manual map (for areas where it is not possible to create digital maps):

- District/ sub-district map commensurate to identified threats

- Thumbtacks - Scissors - Colored string

- Sticky notes (colored paper)

Manual map:

- Sticking board (for use in temporary shelters).

- District/ sub-district map commensurate to identified threats

- Thumbtacks - Scissors

- Colored strings - Sticky notes (colored paper)

Digital map:

- Laptop

- Printed following creation on computer

Digital map:

- Laptop

- LCD (optional)

Type of map Manual map:

- A hazard map showing priority threats that have been analyzed and calculated

- A vulnerability map identifying areas that may be at risk in the event of previously identified threats

Manual map:

- Capacity map (the condition of primary and referral facilities)

- Map of services (mobile health service points)

Digital map:

The content is the same as the manual map and can be updated annually as the situation develops

Digital map:

- Infographics

- Coordination meeting materials

- Daily situation reports 2.4 CONTINGENCY PLANS FOR THE HEALTH SECTOR

The contingency plan for the health sector is a formal planning process designed to handle emergency situations and health crises based on scenarios prepared by the health sector or developed by the sub-national government. It contains defined technical and managerial measures and a mutually agreed-upon response system to prevent or better manage emergency situations.

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18 2.4.1 Risk Analysis

The contingency plan document must be prepared in an operational manner in accordance with the type of disaster threat that has occurred or has the potential to occur in the area. Risk analysis is the first step in prioritizing which type of disaster threat to develop into a contingency plan. Risk analysis involves an assessment of potential disaster threats and their impacts so that mitigation and preparedness can be prioritized. The provincial health office must analyze disaster risk throughout its district/ city, while district/ city health offices must identify and analyze disaster risks and health crises in their area.

Several tools, methods, and formulas can be used to carry out risk analysis.

However, the principle is to identify the type of threat, calculate its impact, and perform the analysis.

1. Probability Scale and Impact Scale Methods

This method involves identifying the possibility of a disaster occurring and the resulting impact. The first step is to identify the type of hazard/ disaster, which can be categorized as natural, non-natural, or social disasters. A health crisis occurs when a disaster impacts public health and requires a rapid response outside the normal course of events. Indicators for potential disaster threats include the types of disaster threats and the number of disaster occurrences in the area over the past 25 years. Each type of hazard/ disaster has unique characteristics and is closely related to the problems it can cause. Data on disaster events will make it easier to assess the types of disasters that have occurred and are predicted to occur in an area.

After determining the types of disasters that have occurred and are predicted to occur, the probability and impact of the disaster are assessed. Probability is benchmarked by assigning weights/ scores to the possibility of a hazard/ disaster occurring. Impact is benchmarked by weighting/ scoring the impact of the threat.

Table 2.2 Probability Scale (P)

Variable Evaluation

Mark Information

Very Frequent

5 Predicted to occur in 1-5 years, or in a matter of months or even days

Frequent 4 Common occurrence, estimated to occur once every 10 years

Occassionaly 3 Occasional occurrence, estimated to occur once every 20 years

Infrequent 2 An unusual occurrence, not expected to occur more than once every 100 years

Very Infrequent

1 Occurrence is very atypical/ unusual, not expected to occur more than once every 500 years

Table 2.3 Impact Scale (D)

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Variable Evaluation

Mark Information

Catastrophic 5 Nearly 100% of the area is destroyed and completely paralyzed

Critical 4 50-75% of the area is destroyed and crippled, requiring outside assistance

Significant 3 10-50% of the area is destroyed, requiring local resources

Minor 2 Less than 10% of the area is affected, with slight interference

Negligible 1 The impact of the disaster has no effect

Table 2.4 Impact Indicators

Indicators Parameters

1. Impact on Humans Death

Injury ED visit

2. Disrupted Health Services Availability of health workers

3. Impact on Society Number of IDPs

4. Disrupted Health Facilities Facility damage

After assessing the probability and impact, the results are entered into the following Risk Matrix.

IMPACT SCALE Very Low Risk Low Risk Moderate Risk High Risk Very High Risk PROBABILITY SCALE

2. Risk Assessment Matrix Method

This method uses the variables hazard, vulnerability, and capacity for risk assessment.

● The Hazard Variable includes the state or potential of experiencing a disaster, which may result in loss of life, injury, or material loss/ damage. Assessment is carried out on the elements of each variable based on empirical data, experience, and estimates with the following information:

1 = Hazard/ threat with low risk

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20 2 = Hazard/ threat with moderate risk 3 = Hazard/ threat with high risk

The value of the hazard characteristics variable is the result of the sum of the values of frequency, intensity, impact, extent, and duration.

● The Vulnerability Variable includes the condition or behavior of the community that causes an inability to deal with a hazard or threat of a health crisis. Assessment is carried out on the elements of each variable based on empirical data, experience, and estimates with the following information:

1 = low vulnerability 2 = moderate vulnerability 3 = high vulnerability

The value of the vulnerability characteristic variable is the result of the sum of the physical, social, and economic values.

● The Capacity Variable includes the strengths and potential possessed by individuals, families, communities, and governments that enable them to prevent, mitigate, prepare for, respond quickly, or recover from a health crisis. Assessment is carried out on the elements of each variable based on empirical data, experience, and estimates with the following information:

1 = high capacity 2 = moderate capacity 3 = high capacity

The value of the capacity variable is the result of the sum of the values of policy, preparedness, and community participation.

Table 2.5 Risk Analysis using the Risk Assessment Matrix

No. Variable Disaster

Earthq uake

Covid- 19

Flash Flood

Inter- Village Dispute I Hazard

- Frequency

* Overview of the possibility of a hazard/

threat occurring - Intensity

* Force and speed measured quantitatively/

qualitatively, e.g. height of flooding - Impact

* Impact of hazard on daily life: severe, moderate, mild

- Extent

* Extent of affected geography, e.g. number of sub-districts impacted

- Period

* For how long does the disaster/ emergency last

TOTAL II Vulnerability

- Physical

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No. Variable Disaster

Earthq uake

Covid- 19

Flash Flood

Inter- Village Dispute

* Resilience and structure of buildings, resilience of transportation and telecommunications systems, against disaster

- Social

* Extent of vulnerable groups, public health status

- Economic

* Economic fragility in the face of hazards/

threats Total III Capacity

- Policy

* Are policies, regulations of the law, by- laws, protocols in place regarding health crisis management

- Preparedness

* Is an early warning system or contingency plan in place

- Community Participation

* Do people care about, and engage in, disaster management

Total Score

3. Simple Method of Calculating Risk Analysis

After carrying out the above risk analysis calculations, the types of disasters will be categorized as having very high risk, high risk, medium risk, low risk, or very low risk. The types of disasters that fall into the very high and high categories are prioritized for disaster management. Furthermore, the Health Office can develop disaster management scenarios, including mapping capacity and needs for disaster management.

Examples of risk analysis in determining disaster priorities using the probability scale and impact scale methods:

Step 1: Identify the probability of a potential disaster threat (probability)

DISASTER PROBABILITY (P)

Earthquake 4

Flash flood 5

Landslide 4

Covid-19 pandemic 4

Inter-village dispute 2

Dengue fever 3

etc.

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Step 2: Evaluate the impact of the disaster

All disaster types selected above are evaluated for impact.

a) Earthquake

Earthquake of 2018 Impact

Indicator Daily Data Earthquake of 2018

Fatalities 3 30 4

Injuries 5 50 4

ED visits 20 200 4

Availability of HP 97% 50% 3

IDPs - 1000 4

Damaged facilities - 40% 3

Risk 22/6 = 3.6

Flash Flood of 2019 Impact

Indicator Daily Data Flash Flood of 2019

Fatalities 3 3 0

Injuries 5 5 0

ED visits 20 24 1

IDPs - 100 2

Damaged facilities - 10% 1

Risk 4/6 = .6

Dengue Fever of 2005 Impact

Indicator Daily Data Dengue Fever of 2005

Fatalities 3 3 0

Injuries 5 30 2

ED visits 20 30 2

IDPs - - 0

Damaged facilities - - -

Risk 4/6 = .6

The third step: Multiply the probability with the resulting impact using the risk matrix table

IMPACT SCALE Earthquake; Covid-19 Inter-village dispute Dengue fever Landslide Flash flood

PROBABILITY SCALE

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23 4. Prioritization

The results of the calculation of the threat and impact probability analysis will reveal the risk scale. The risk scale is generally categorized as low, medium, high, and very high risk. Using the matrix and/or analysis calculation results from the various risk analysis approaches above, an example of disaster risk and health crisis categorization is obtained, as follows:

DISASTER RISK

Earthquake High

Flash Flood Moderate

Landslide Moderate

Covid-19 Pandemic High

Inter-Village Dispute Low

Dengue Fever Low

Based on the table above, the types of disasters that are prioritized for disaster management are earthquakes and the COVID-19 pandemic. Furthermore, the Health Office prepares scenarios and specific hazard plans for earthquakes and the COVID-19 pandemic in the disaster management plan document at the Health Office (contingency plan).

2.4.2 Contingency Planning

The health crisis response contingency plan is highly dependent on the risk analysis and scenarios developed. Evidence-based contingency plans, including operational action plans, are the foundation of an appropriate and effective response in the event of a disaster/ health crisis. Therefore, the preparation of scenarios must be detailed by taking into account the impacts that may occur.

Scenarios are the basis for determining initial response plans, communications, prehospital services, clinical management, including sectoral and cross-sectoral roles and responsibilities that will be detailed (WHO 2019).

Scenario preparation can be conducted in two ways: first, scenario preparation can be initiated by detailing the chronology in advance, and second, by preparing detailed calculations of impact assumptions. In the first way, a chronological explanation of the incident can be written down and impact assumptions and a general management plan can be compiled. In the second way, the calculation of the assumed impact of the disaster on each sector can be detailed and the impact assumptions can be summarized briefly, followed by writing down the chronology of the disaster events. Essentially, these two ways of preparing scenarios can complement each other, either by writing them in general and then detailing them, or by first conducting detailed impact calculations and then summarizing them generally in a scenario.

The scenario development stage in the health crisis response contingency plan is a step that cannot be overlooked after conducting a risk analysis. Developing scenarios that are close to actual events is urgently needed so that policy and strategic planning can be carried out, including carrying out detailed calculations of

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the logistical needs, human resources, and budget needed to address the scenario problems.

A. Scenario Development

1) Definition of Event Scenario

A clear and detailed picture of the expected disaster, including its location, time, duration, and impact, constitutes an event scenario. Meanwhile, scenario development involves predicting the events that may arise from a disaster.

Event scenarios must be based on data, scientific studies, and official analysis from authoritative institutions with credibility in disaster and health crises. Input from experts and resource persons who are competent or come from authorized instrumentalities should also be taken into account to provide perspectives, considerations, and directions regarding hazards and disaster risk factors in the region or territory. Additionally, scenario development can consider the history of the worst disaster ever experienced.

Event scenarios should consider the time, location, origin or cause, intensity, speed of occurrence, distance, process, affected area, and potential for further or secondary hazards.

Detailed impact assumption calculations form the basis for event scenario development. Impact assumptions estimate the negative impacts that may result from a disaster. Direct impact projections are developed based on event scenarios and risk or hazard maps, considering aspects of vulnerability and capacity of the affected public, private sector, or community. Impact assumptions cover the environment, population, economy, infrastructure or physical buildings, government civil services, health, and health facilities.

In addition to official institutions' data and impact analysis, impact assumptions can refer to the history of events or assumptions most likely to occur. Stakeholder agreement can also form the basis for impact assumption development.

2) Defining Specific Threats to Serve as Scenarios

Contingency plans for managing health crises are prepared for specific hazards or disasters, while taking into account potential follow-up and secondary disasters. For example, an earthquake may be followed by a tsunami and liquefaction disaster, as was the case in the Central Sulawesi disaster in 2018. Similarly, prolonged flooding may lead to an outbreak of diarrhea in affected communities.

The identification of the specific threat for which a contingency plan will be developed is based on risk analysis that considers the likelihood of occurrence and impact. Thus, each sub-national region may require multiple contingency plans.

The health office faces two situations when preparing contingency plans in the health sector:

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1. The first situation arises if the Sub-National Disaster Management Agency (BPBD) has developed a contingency plan for the hazards or disasters that may occur in the sub-national region.

If the contingency plan scenario is already in place, the health office will review the scenario and develop a scenario that focuses on health impacts.

Sub-national contingency plans are generally developed by cross-sectoral teams, including the health sector. Nevertheless, it is advisable for the health sector to develop more detailed contingency plans for health crises, such as how the health office will activate health clusters, organize and control the assistance of health volunteers, manage health centers, hospitals and clinics, and coordinate related health issues with other sectors.

In general, the event scenario includes the time of occurrence, location, event trigger, primary hazard, such as the number of affected population and general damage, early warning, the scope of the affected area, such as the number of sub-districts and villages, secondary hazards, such as disease outbreaks resulting from the disaster's environmental situation, and other secondary hazards, such as pandemic situations.

2. The second situation arises if there is no sub-national contingency plan in place yet.

In this case, scenario development must be carried out in stages, starting with identifying the priorities of risk analysis, making impact assumptions, and then developing scenarios. The health sector can then socialize and involve cross-sectoral teams in the development of the health disaster/

crisis contingency plan.

B. Impact Assumptions

1) Calculating the Health Impact of Disasters

After selecting the priority of threats and determining their level of risk, the next step is to estimate or make assumptions about the possible health impacts that may occur. In general, every disaster event has a direct or indirect impact on health. Every disaster event has an impact on public health and the healthcare system as follows:

1. Direct impacts on public health, such as physical trauma, death, injuries, morbidity, and psychological trauma.

2. Direct impacts on the healthcare system, such as damage to health facilities, hospitals, laboratories, and healthcare workers becoming victims.

3. Indirect impacts on public health, such as hindering immunization programs due to the disaster situation, inability to carry out immunization due to displaced target communities, disruption of disease programs such as TB and HIV, and an increase in maternal and infant mortality rates due to disasters, among others.

4. Indirect impacts on the healthcare system, such as disrupted access to roads, resulting in longer referral times, the inability of hospitals to perform surgical procedures due to power outages, and contaminated

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water sources and broken pipes in community health centers due to disasters, making it impossible to perform deliveries in health centers, among others.

These health impacts must be predicted and calculated by the scenario development team. The health department, as the coordinator of the health sector in the area, must calculate these impacts in detail to visualize the health issues that must be addressed in this contingency plan. Similarly, at the level of community health centers and hospitals, they can understand the scenarios and then plan responses in their respective preparedness plans related to the health contingency plan made by the health department. There are many table models to facilitate the calculation of health impact predictions, here is one example:

1. Impact on health aspects No. Sub-

distri ct

Impact IDPs

Fatalities Serious injuries/

inpatient care

Minor injuries/

outpatient care

Total Vulnerable Groups

Evacua tion points 1

2 3 4 TOTAL

2. Impact on health facilities No. Facility/

Asset

Number

Threatened (Unit)

Impact Remark

Light Moderate Heavy Lost 1 Hospital

3 Puskesmas 4 Pustu

Another table model combines everything:

Threats:

Location of incident: Province: District: District: Urban Village: Rural Village:

No. Risk/ impact Total

1 Death

2 Serious injuries 3 Minor injuries 4 Vulnerable groups

Pregnant mothers Babies

Toddlers

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27 Threats:

Location of incident: Province: District: District: Urban Village: Rural Village:

No. Risk/ impact Total

Elderly

Disabled persons 5 Evacuation points 6 Disease occurrence:

Diarrhea ISPA DHF Etc.

7 Damage to Health Facilities (Puskesmas) Lightly damaged

Moderately damaged Heavily damaged

8 Damage to Health Facilities (Hospitals) Lightly damaged

Moderately damaged Heavily damaged

9 Damage to Health Facilities (Auxiliary Puskesmas) Lightly damaged

Moderately damaged Heavily damaged 10 Etc.

The more detailed the health impact calculation, the better the contingency plan scenario will be. It will be easier to formulate policies, strategies, and calculate future budget requirements. Therefore, the drafting team must consider previous disaster experiences, impacts that are certain to occur, impacts that may occur, and other uncertainties that may affect the health sector.

In general, the impact of disasters on the health system and health services is rarely taken into account, even though every disaster can affect the achievement of health service performance and programs. This impact should be calculated in the scenario and can be written qualitatively or narratively as in the example table below:

Impact on healthcare programs.

- during one month of emergency response, immunization coverage decreased

- during one month of emergency response there was an increase in maternal mortality

- unable to track TB patients who are under medication supervision

- unable to carry out epidemiological investigations due to large-scale restrictions

- etc.